Prevention and Management of Dental Office Emergencies

Emergencies most common to dental practice

1. vasovagal syncope (passing out), orthostatic hypertension 50% of emergencies
2. respiratory distress
3. altered consciousness
4. chest pain

Factors that increase the likelihood of emergencies

-increased number of medically compromised individuals seeking care
-medical advances in drug therapy
-longer appointments
-increased used of drugs in oral healthcare settings

about 90% of medical emergencies are

preventable

The best management of a dental office emergency is

prevention and preparation

Ways to prevent a medical emergency

-comprehensive health history and risk assessment
-treatment modification
-documentation

Health History and Risk Assessment

-past and present health status
-problems a patient might not be aware of
-

Vital signs

temperature: 98.6F, elevated may indicate viral infection

pulse: 60-100 bpm, strength and rate and intervals between ( v thready, strong ^)

respirations: 12-20rpm, try to not let patient see you counting

blood pressure: 120/80 or lower, if giving anesthesia take before and after administration** pay attention to diastolic reading

Leading cause of death in the US

heart disease

Signs of anxiety

-sweating
-increase in BP, HR
-restlessness
-nervous conversation
-history of cancelled appointments

Ways to reduce patient's stress

-build rapport with patient
-communication
-minimize wait time
-pain control
-follow up

American Society of Anesthesiologists (ASA) Classifications

ASA I: normal health, no anxiety

ASA II: mild disease/ extreme anxiety (pregnant, obese person, social drinker/smoker, well controlled diabetes)

ASA III: severe disease (uncontrolled diabetes, hypertension)

ASA IV: disease threatens life

ASA V: near death

ASA VI: moribund

Drugs in an emergency kit

-epinephrine: cardiac events
-histamine blocker: localized allergic reactions
-nitroglycerin: cardiac related events
-bronchodilator: asthma attacks, bronchospasm
-oral glucose: hypoglycemic patients
-aspirin: myocardial infarction
-pulse oximeter: checks oxygen saturation to know whether to administer more

Vasovagal syncope

-"simple fainting"
-sudden, temporary loss of consciousness
-induced by stress/anxiety
-patients maintain pulse and ability to breathe
-blood rushes to extremities
-can lead to seizures or death if not resolved
-common in people 16-30s, NOT usually seen in children so if it does happen it can be due to an underlying cause
-men more likely to pass out

Signs and symptoms of syncope

-pallor (paleness)
-light headedness
-sweating

Treatment of syncope

-lay patient supine, elevate lower extremities
-monitor vital signs
-call 911 if symptoms don't resolve or if it occurs again
-at risk for 2nd episode for 15 minutes after regaining consciousness

Prevention of emergencies

-identify the risks
-REVIEW MED HX!
-keep the patient supine (especially during administration of anesthesia)
-do not allow patient to change posture rapidly
-know of allergies and severity
-make sure patient has epi pen, inhalers, medications if needed
-delay treatment
-request medical clearance
-short appointments
-check your dental instruments in case tips break

Causes of altered consciousness

-vasovagal reaction
-stroke
-acute cardiac event
-hypo or hyper glycemia

Hyperventilation

-precipitated by fear
-imbalance, lost too much carbon dioxide and have too much oxygen
-if not treated properly can lead to syncope

Signs and symptoms of hyperventilation

-air hunger
-rapid respiratory rate
-carpopedal symptoms

Treatment of hyperventilation

-try to calm the patient
-have patient cup their hands over their mouth/nose
-coach to take slower breaths
-call 911 if attack cannot be broken

Asthma

-can be caused by an external stimulus (chemical, environment)
-most common cause of respiratory distress
-constriction of bronchial and bronchiolar muscles
-cold air can be a trigger

Signs and symptoms of asthma

-wheezing
-chest tightness
-coughing
-cyanosis

Treatment of asthma

-sit patient up in "tripod" position
-administer inhaler, most patients with asthma will have inhaler with them ** check if they do and if expired
-call 911 if symptoms do not resolve

Hypoglycemia

-low blood glucose levels
-can appear as if the patient is drunk or in altered state of consciousness
-prescribed insulin without eating properly
-Type I insulin dependent, Type II oral glucose meds

Signs and symptoms of hypoglycemia

-altered mental status
-irritability
-sweating
-tachycardia
-cold, clammy skin
-lack of coordination
-can lead to seizure if not treated quickly

Management of hypoglycemia

conscious patient:
-fruit juice, soda

unconscious patient:
-glucose gel from emergency kit
-glucagon IM
-50% dextrose IV
-call 911

Allergic reaction

-can be localized (mild) or generalized (anaphylaxis)
mild reaction:
-flushed, swlling, rash, delayed response
severe reaction:
-respiratory distress, rapid onset, hypotension

Treatment of allergic reaction

-supine posiiton
-administer benadryl, steroid, epi pen (self attenuated), epinephrine
-accurate dosage required for children/adults - do not OD!

Cardiac arrest/Myocardial infarction

-supply of oxygenated blood to myocardium is reduced
-usually happens when the heart is at rest

Signs and symptoms of cardiac arrest/MI

-squeezing sensation in the chest
-pain in chest, arms, neck, jaw
-women can have different symptoms than men:***
nauseous, lower back pain

Management of MI

-seat patient upright and stop dental treatment
-MONA:
morphine IV/IM, oxygen, nitroglycerin, aspirin (325mg chewed)
-if no morphine, 50:50 ratio of nitrous oxide and oxygen
-up to 3 doses of nitro every 10 mins?

Nitroglycerin is only good for ____ after opened

3 months

Aspirated and ingested objects

-aspiration of object into the bronchi or lung
-ingestion of object into the esophagus and
-extracted tooth, crowns, instruments, cotton rolls, etc

Signs and symptoms of aspiration/ingestion

-coughing
-choking

Management of aspiration/ingestion

-place patient in upright position
-flat plate or chest Xray
-bronchoscopy if aspirated
-strain stools if ingested